Patient Safety & Quality Improvement USMLE Step 1 Practice Question

A 28-year-old woman presents to the emergency department with fever, hypotension, and altered mental status. Blood cultures are drawn and empiric broad-spectrum antibiotics are initiated. Over the next 72 hours, she is cared for by multiple teams across different units. The electronic health record documents antimicrobial orders from four separate physicians, none aware of the others' prescriptions. Nursing staff report difficulty accessing culture results from the microbiology lab, and the initial culture result (E. coli susceptible to ceftriaxone) is never communicated to the primary team. The patient ultimately receives appropriate therapy, but the near-miss event prompts a quality improvement investigation. Which of the following tools is most appropriate for systematically identifying the root causes of this communication and coordination failure?